Brickyard Healthcare - Richmond Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fluids were available and within reach and failed to ensure call lights were within reach for 3 of 3 residents reviewed for accommodation of needs (Resident 41, Resident 10 and Resident 5).

Inspectors wroteBased on interview and record review, the facility failed to file a grievance for a resident with missing clothing for 1 of 1 resident reviewed for grievances. (Resident 34)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan interventions were implemented for a resident's call light to be within reach and failed to implement a touch call light for a resident at high risk for falls for 1 of 2 residents reviewed for care plan implementation of interventions. (Resident 41).

Inspectors wroteBased on interview and record review, the facility failed to initiate the continuation of care, related to the administration of a resident's comfort eye drops, for 1 of 1 resident reviewed for Quality of Care. (Resident 9)

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer a resident his elbow splint, per the restorative nursing plan, for 1 of 2 residents reviewed for positioning and mobility. (Resident 1)

Inspectors wroteBased on observation, interview and record review the facility failed to provide routine dental service for a resident with improper fitting dentures for 1 of 3 residents reviewed for dental services (Resident 5).

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 residents reviewed for abuse (Resident D and Resident F) were free from sexual abuse from a resident with known inappropriate behaviors (Resident E), resulting in inappropriate touching (Resident D); and psychological harm of feeling upset and gross (Resident F).

Inspectors wroteBased on interview and record review, the facility staff failed to be knowledgeable of behavioral health interventions for 1 of 5 residents review for behavioral health management. (Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required more than limited assistance with transfers received adequate assistance and supervision to prevent accidents related to only one staff person assisting during a transfer without the utilization of gait belt and ensure the resident's wheelchair was free from sharp objects resulting in the resident requiring 18 sutures to the left lower leg for 1 of 3 residents reviewed for accidents (Resident C). This deficient practice was corrected on 2/28/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: [...]

Inspectors wroteBased on interview and record review, the facility failed to document a resident's death, the notification of a resident's death to the physician, family, responsible party, disposition of the resident's body, personal possessions, medications, or a complete and accurate notation of the resident's condition preceding the resident's death in the clinical record for 1 of 1 resident reviewed for death (Resident B).

Inspectors wroteBased on observation and interview, the facility failed to ensure open medication bottles were dated in 2 of 2 medication carts observed for medication storage and four open, un-identified medications laying in medication drawers in 2 of 2 medication carts observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document self-administration of medications were clinically appropriate for 1 of 6 residents reviewed for medication administration. (Resident T)

Inspectors wroteBased on interview and record review, the facility failed to ensure a proper code status order and care plans were in place for 2 of 4 residents reviewed for code status and care plans. (Resident EE & Resident GG)

Inspectors wroteBased on interview and record review the facility failed to provide privacy for residents' medical condition by taking pictures and videos on personal cell phones for 2 of 4 residents reviewed for privacy (Resident KK and Resident W).

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize smoking aprons during smoking for safety of the residents as assessed for 3 of 3 residents reviewed for smoking safety (Resident J, Resident Z and Resident BB).

Inspectors wroteBased on interview and record review, the facility failed to obtain physician orders to crush medications for 3 of 5 residents reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to follow-up with monitoring and have an indication for use on a one-time order for Ativan (antianxiety medication) for a resident who was experiencing an acute change in condition for 1 of 3 residents reviewed for change in condition (Resident W).

Inspectors wroteBased on interview and record review, the facility failed to ensure an order and care plan were in place for a resident receiving hospice services for 1 of 3 residents reviewed for hospice. (Resident DD)

Inspectors wroteBased on interview, observations, and record review, the facility failed to ensure Resident 44 had a self-administration of medications assessment completed for 1 of 1 resident reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fresh water daily for 1 of 1 resident reviewed for hydration. (Resident C)

Inspectors wrote1. Based on observation, interview, and record review, the facility failed to follow physician orders for obtaining daily and monthly weights for 2 of 2 residents reviewed for weights. (Resident 6 and 44). 2. Based on observation, interview, and record review, the facility failed to have accurate skin assessments, follow physician orders for no brief while in bed, and have heels floated for 1 of 3 residents reviewed for skin. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to don personal protective equipment (PPE) prior to entering the room of a resident in contact isolation for 1 of 2 residents reviewed for transmission-based precautions (TBP). (Resident 36)

Inspectors wroteBased on interview and record review, the facility failed to complete care plan meetings for residents and their representatives for 2 of 3 residents reviewed for care plan meetings (Resident F and Resident D).

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's infectious disease physician of lab results, as ordered, and obtain a lab, as ordered by the pharmacy, prior to continuing administration of an antibiotic for 1 of 3 residents reviewed for skin conditions. (Resident E)

Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member followed policies for the safe use of a mechanical lift, requiring the operation of the mechanical lift to be conducted by 2 staff members, resulting in a fall from the mechanical lift and a fracture for 1 of 3 residents reviewed for falls and the use of mechanical lifts. (Resident B and CNA 3) The deficient practice was corrected on 4-25-24, prior to the start of the survey, and was therefore past noncompliance. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed and implemented for seizure-like activities for 1 of 3 residents reviewed for falls. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who admitted to the facility with an identified skin concern received timely treatment and services that was later identified with an unstageable pressure ulcer that had worsened and became infected (Resident E) and failed to ensure a resident received treatment for incontinence associated dermatitis (IAD) who was later identified with a stage 3 pressure ulcer (Resident D) for 2 of 3 residents reviewed for skin integrity. The deficient practice was corrected on 2/1/24, prior to the start of the survey, and was therefore past noncompliance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate staffing was available to provide showers, to toilet and/or change residents, transfer residents who utilized a mechanical lift, and conduct dining services in the main dining room. This had the potential to affect 38 of 55 residents that reside in the facility on the Extended Care Unit (ECU).

Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member did not work while experiencing signs and symptoms of a gastrointestinal illness before and during their shift. This had the potential to affect 38 out of 55 residents that reside in the facility.

Inspectors wroteBased on interview and record record review the facility failed report allegations of abuse to the Indiana Department of Health and the Administrator, failed to protect residents after an allegation of abuse for 3 of 13 residents reviewed for abuse (Resident K, Resident Q and Resident R).

Inspectors wroteBased on interview and record review the facility failed to treat and assess a resident experiencing emesis and failed to transport a resident with a change in condition to the hospital timely for 1 of 3 residents reviewed for quality of care (Resident C).

Inspectors wroteBased on interview and record review, the facility failed to ensure oxygen therapy was provided according to physician orders and available for use for 1 of 3 residents reviewed for oxygen therapy. (Resident D)

Inspectors wroteBased on interview and record review the facility failed to maintain a sanitary environment for a resident when a supper tray was stored in the resident's dresser and acquired maggots for 1 of 5 residents reviewed for sanitary conditions (Resident E).

Inspectors wroteBased on interview and record review, the facility failed to ensure a dependent resident received assistance and supervision with toileting to where they were later found on the floor of the bathroom, for an unknown period, for 1 of 3 residents reviewed for activities of daily living (ADLs). (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure skin impairments were assessed on a weekly basis, ensure appropriate treatments were initiated timely for a skin impairment, and ensure continued treatment for a skin impairment for 3 of 4 residents reviewed for skin integrity. (Residents B, D and E)

Inspectors wroteBased on interview and record review, the facility failed to ensure complete documentation of the electronic medication administration records (MAR) and treatment administration records (TAR or ETAR) for 2 of 4 residents reviewed for skin impairment. (Residents B and D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with dementia, a history of agitation, anxiety, and combativeness, remained free from physical and verbal abuse, which resulted in a staff member holding the wrists of a resident during care that was later identified with bruising to the bilateral hands and wrists. Using the reasonable person concept, it was likely that this would lead to chronic or recurrent fear and anxiety. (Resident B) The Immediate Jeopardy began on 4/30/23, when Resident B was held by the wrists during care that was later identified with bruising to the wrist and hands. Area [NAME] President and [NAME] President of Clinical Operations were notified of the Immediate Jeopardy on 5/17/23 at 1:38 p.m. The Past Noncompliance Immediate Jeopardy began on 4/30/2023. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Resident D, F, and G had their facial hair shaved per their preference and failed to provide nail care for dependent residents (Resident J and H) for 5 of 9 residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations were initiated timely for residents with identified weight loss, failed to obtain weights as ordered, and failed to implement weekly weights for a resident identified with significant weight loss for 5 of 8 residents reviewed for nutrition. (Resident 18, 45, F, 22, and 8)

Inspectors wroteBased on interview and record review, the facility failed to ensure a system was in place to review pharmacy reviews and potential recommendations for 4 of 5 residents reviewed for unnecessary medications. (Resident 18, Resident E, Resident 25, and Resident 50)

Inspectors wroteBased on interview and record review, the facility failed to ensure an infection control program that consisted of mapping and tracking infections for 11 of 12 months reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a speciality cup as ordered by the physician, failed to provide a straw to drink with, failed to keep fluids within reach, and failed to provide a whirlpool bath as preferred for 1 of 2 residents reviewed for hydration and 1 of 5 residents reviewed for shower preferences. (Resident 3 and Resident E).

Inspectors wroteBased on interview and record review, the facility failed to ensure a physical and verbal abuse event was reported to the Administrator and state agency timely for 1 of 4 residents reviewed for abuse. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate transfer and discharge paperwork provided to a resident upon transfer to an area hospital was included in the resident's clinical record for 2 of 5 residents reviewed for hospitalization. (Resident H and 50)

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold information when a resident was sent to the hospital. This affected 2 of 5 residents reviewed for hospitalization. (Residents H and 50)

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessment regarding to mood and behavior for 1 of 2 residents reviewed for dementia care (Resident B), the use of corrective lenses for 1 of 2 residents reviewed for vision (Resident 26), and complete the pain assessment portion for 1 of 3 residents reviewed for pain (Resident H).

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for Resident E's use of medication to treat her hypothyroidism and failed to develop a care plan for constipation for a resident with a diagnosis of constipation for 2 of 5 residents reviewed for unnecessary medications. (Resident E and Resident H)

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge summary was completed in full for 1 of 3 closed records reviewed. (Resident 54)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Resident D's corrective lenses were in place for 1 of 2 residents reviewed for corrective lenses.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an ongoing activity program for 2 of 2 residents reviewed for activities (Resident 11 and Resident 3).

Inspectors wroteBased on interview and record review the facility failed to follow up and ensure a resident had proper preparation prior to a procedure resulting in the procedure not being able to be completed, failed to complete neurological assessments after a resident fell and hit his head, failed to apply a palm protector as ordered by the physician, apply a rolled towel as ordered by the physician, and failed to obtain weekly weights for congestive heart failure (CHF) for 1 of 7 residents reviewed for accidents, 1 of 4 residents reviewed for quality of care, 1 of 2 residents reviewed for positioning/mobility, and 1 of 8 residents reviewed for nutrition. (Resident 20, Resident 36, Resident J and Resident 35)

Inspectors wroteBased on interview, observation, and record review, the facility failed to timely follow up on recommendation for the management of Resident F's stage three pressure area and failed to provide pressure relieving boots or float heels for Resident 20's unstageable pressure ulcer to the right heel for 2 of 6 residents reviewed for pressure ulcers.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Resident 23's foot pedals were in place while she was in her wheelchair for 1 of 2 residents reviewed for assistive devices.

Inspectors wroteBased on observation, interview and record review the facility failed to supervise a resident during meals as instructed by the Speech Therapist, failed to implement fall interventions, and failed to ensure adequate supervision and known whereabouts of a resident for 4 of 7 residents reviewed for accidents (Resident 3, Resident 49, Resident 36 and Resident 23).

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor intake totals for a dependent resident who utilized a gastrostomy tube (a tube that is inserted into the stomach through the abdominal wall for nutrition) and failed to follow up when a resident's residual was less than 100 milliliters per MD orders. This affected 2 of 2 residents reviewed for gastrostomy tubes. (Residents 4 and 14)

Inspectors wroteBased on interview and record review the facility failed to provide pain management for a resident who had a fall with a fracture and failed to follow up PRN (as needed) pain medicine for a resident who had ineffective pain relief for 2 of 3 resident's reviewed for pain (Resident 36 and Resident E).

Inspectors wroteBased on interview and record review, the facility failed to ensure complete documentation of pre and/or post dialysis evaluations for 1 of 1 resident reviewed for dialysis. (Resident 28)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate approach of care and implement interventions for a resident with dementia with a history of agitation, anxiety, and combativeness, for 1 of 2 residents reviewed for dementia care. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure influenza and pneumococcal immunizations were offered and/or administered for 3 of 5 residents reviewed for immunizations. (Residents H, 29, and 49)